If you had, for example, a really
pressing health problem, say, that a particular group of people had much worse
health outcomes than the rest of the population, and then you decided to take
steps to solve this problem, what would you do?

One of the obvious answers might
be to provide a health workforce to help solve the problem. And one of the most
obvious (and therefore most studied) components of a health workforce is
doctors.

We know that Aboriginal and
Torres Strait Islander people have much worse outcomes in health than other
Australians. If I told you that there were about 22,000 GPs across the country,
how many do you think would work primarily in Aboriginal Medical Services?

So would you be surprised to hear
that there are 333 GPs across the country who say their main place of work is
in an Aboriginal Medical Service. That’s not a typo. That’s 333. 92 of these
were doctors training to be GPs, who are often on 6 month placements.

At this point in a blog post
which contains numbers, it’s customary to quibble about the statistics. I don’t
wish to disappoint you, so here goes:

You: Where are these
numbers from? Surely they’re just made up like most statistics?

Me: No, they’re from the
2009 medical workforce survey. Every doctor has to be registered with the
Medical Board of Australia, and when they renew
they get a survey about their work. These figures were tucked away in the
latest release. So they’re a little behind the times, but they are the best
figures we have.

You:But it’s not an accurate reflection of the actual number of
doctors working in Aboriginal health is it? I mean most doctors see Aboriginal
patients in their practice don’t they? They wouldn’t be counted in this.

Me: That’s true. This
only counts those who say they primarily work in Aboriginal health. It probably
doesn’t include private GPs seeing Aboriginal patients in their normal clinic,
and it may not include GPs who work part time in an Aboriginal Medical service and
part time in another clinic.

You: And this isn’t just
about numbers. Don’t they need to be in the right place, too. It’s pretty hard
to get doctors to go rural.

Me: You’re right again.
The largest number of Aboriginal and Torres Strait Islander people live in New
South Wales. There are 76 GPs in NSW and 77 in the NT. The largest population
numerically is in West and South West Sydney. But, still, proportionately more
Aboriginal people live in remote and rural parts of Australia.

You: And Doctors aren’t the
be all and end all of a medical service. There is probably some compensation
from the huge numbers of Aboriginal Health workers and nurses working in this
area.

Me: You’re right, doctors
aren’t the whole story. Though I doubt the numbers are made up for by other
health professions – the other workers in AMSs are often doing non-doctor jobs.
And I’m not aware of any figures for these other professions, though this may
become clearer with national registration of Aboriginal Health Workers.

This really is the best
information we have. (At least, the best information I know of – if you know of
better stats on this, I’d love to hear from you.) And the bottom line is that
for the size of the problem, even allowing for the caveats above, the medical
workforce is pitifully small for the size of the problem. It leaves a tiny
number of doctors with a large and complex workload. And, because Medicare
revenue is generated by doctors, it leaves Aboriginal medical services
disadvantaged when it comes to generating funding, too.

There are many reasons for this –
those are for another post – but in the mean time, what can you do?
If you’re a GP, do take the opportunity to work in Aboriginal health if you get
half a chance.

If you’re someone with policy
responsibility, think about what needs to be done to close the gap, what
workforce is required to do it, and where they need to be to do it.

If you’re neither of these, stay informed, ask questions and advocate. I’ll post more on this later.

Update
The AIHW released a little more information on this recently: The 2010 medical workforce survey. Not much is different, but there is a slight change in emphasis. Gone is the state by state breakdown, but instead there is a division into clinical and non-clinical (managerial, education, research and public health roles, I would imagine). So, here goes:

There are 310 doctors working clinically in Aboriginal Medical Services in clinical roles. Across the whole country. Another 35 work in non-clinical roles. They work on average just over 36 hours per week (compare over 23,770 in "private practice", over 17,000 of these GPs at an average of 41.23 hours per week). You'll notice that's fewer doctors working fewer hours. (Guilty m'lud).

Yes, let's quibble aboout the figures. But in the end, I suspect that all the quibbling in the world can't hide the fact that we are medically understaffing the services required to close the gap.

Don't go away too gloomy, though. Aboriginal Medical Service do need more doctors, especially in rural areas, but there is evidence that they do extraordinarily successful work without enough!

Update 2013
Well, look! The results of the 2011 Medical Workforce Survey have just been releasedand there are now 532 doctors practicing in an Aboriginal Medical Service setting, 483 of these clinically. Compare this to over 33,000 GPs, over 33,000 in hospital medicine and over 1500 in "Community Health Care service" setting. The figures for doctors in an Aboriginal Medical Service aren't broken down by hours worked or by state this time (yet?) so this is all we have. Slightly more than previous years, but still a small and select group!

There are 546 doctors working in Aboriginal health services. 514 of these work clinically. This table is tucked away at the back of the PDF, with the main narrative saying merely that 0.7% of all doctors work in Aboriginal Health Services. 1.54% of the GP workforce work in Aboriginal Health Services.

It's also interesting to note that the number of hours worked on average is less than other GPs (hello, recruitment strategy!) but also that the AMS medical workforce is 50/50 male female and is younger than the mainstream GP workforce. I see signs of sustainability into the future here.

Finally, a comment from the press release - 35% of the whole medical workforce are GPs and 35% are Specialists. I'd love to hear how that compares to other countries. Given that GPs see 85% of the population each year for 6% of the health budget, and we know that most care happens in the community, I'd be wondering if we need a higher proportion of GPs than that. I'd love to hear what you think.

There are now 697 doctors who say their main work setting is in an Aboriginal Health Service, with 664 of these working clinically.

For context, in total there were 40,527 doctors working as GPs and 85,510 doctors in total. so there are 1.7% of GPs or 0.8% of total doctors working in an Aboriginal Health Service setting. That's an increase, though with the average number of hours per week being slightly less, there's slightly more of a workforce shortage than that headcount suggests. (We also know that consultations in an Aboriginal Health Service tend to be longer than in private practice - see here and here - so, again, a simple headcount underestimates the workforce shortage,)

Of course many private GPs and community health services will also see many Aboriginal and Torres Strait Islander patients.

This year's data has little further information about who these doctors are or where in Australia they work.

Wednesday, March 7, 2012

Words are important. Sticks and
stones might break bones, but words can certainly cause quite a bit of harm. So
it’s worth just taking a moment to set out some of the thinking behind
terminology I’ll be using on the blog, and my thinking behind it. Have you ever
read a more boring blog sentence? Well, let’s see if we can make this a fun
post. Or failing that, a short one.

The thinking behind what we call
Aboriginal and Torres Strait Islander peoples has been heavily influenced by
colonisation without us even noticing. Aboriginal
is an English word which has come to mean the diverse group of peoples who are
the original inhabitants of the land masses we now call mainland Australia and
Tasmania. Torres Strait Islanders
are the group of people who originally inhabited the islands between the northcoast of Queensland and Papua New Guinea. It’s intriguing that the name we’ve
given references a Spanish explorer. I’ll try to write Aboriginal and Torres
Strait Islander people when that’s what I mean. Much of the time I’ll write
Aboriginal and I’ll mean to include Torres Strait Islanders too, really just
for clear English purposes – which I am a bit sorry about, as should English
trump the needs of Aboriginal and Torres Strait Islanders once again? I won’t
be using the term Aborigine, as I find that dehumanising – it’s all too easy to
forget we’re talking about people. And I won’t be using ATSI either, as
abbreviations are usually a way of using jargon that allows us to forget the
concepts behind the words.

I’ll use indigenous in the
context of non-indigenous, meaning people who are not Aboriginal or Torres
Strait Islander. I’ll also use indigenous when I want to talk about the
indigenous people of other countries, as, for example, in the UN Declaration onthe Rights of Indigenous Peoples.

Other phrases it’s worth being
clear on are AMS or Aboriginal Medical Service, which is a primary care service
servicing predominantly Aboriginal and Torres Strait Islander people. An
Aboriginal Community Controlled Heath Organisation (ACCHO), are essentially
owned and run by their local communities. Not all AMSs are ACCHOs – Inala in
Queensland is an example – and there are some ACCHOs which are not AMSs,
providing social rather than health care. Often, the term Medical Service
doesn’t do these organisations justice, as that is only a part of what they do,
and they are much more than a doctor’s surgery that happens to see Aboriginal
patients.

And, just to put a nice cap on
all the confusion, there’s Close the Gap and Closing the Gap. Surely they must
be the same thing? I’m afraid not. Closethe Gap is the campaign that you’ve heard of, kick-started by the then
Social Justice Commissioner, Tom Calma, and supported by Oxfam and led by a
range of Aboriginal organisations supported by a large number of non-indigenous
health and reconciliation organisations. If you’re reading this, take a moment
to sign the pledge, and think about joining or organising a morning tea for
National Close the Gap day on March 22nd.

Closing the Gap on the other hand, is the government program with 6
targets across a range of health, education, and social measures to, er, close
the gap. Oh, it does get confusing.

So, that’s cleared that up, then.
And with a hop and a skip we move on to the next post.